Volume 7, Issue 3 (9-2018)                   3dj 2018, 7(3): 115-122 | Back to browse issues page

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Ghamari M, Ebrahimi Khaneghah A, Sefidi F, Ghasemi S. Prescription of Antibiotics and Corticosteroids Following Endodontic Procedures: Study of General Dentists in Qazvin, Iran. 3dj 2018; 7 (3) :115-122
URL: http://3dj.gums.ac.ir/article-1-286-en.html
1- Assistant Professor, Department of Endodontics, Shool of Dentistry, Qazvin University of Medical Sciences, Qazvin, Iran.
2- Assistant Professor, Department of Pediatric Dentistry, Shool of Dentistry, Qazvin University of Medical Sciences, Qazvin, Iran.
3- PhD. Student, Department of Educational Psychology, Shool of Education, Zanjan Branch, Islamic Azad University, Zanjan, Iran.
4- Assistant professor, Department of Restorative Dentistry, School of Dentistry,, Hamadan University of Medical Sciences, Hamadan, Iran.
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1. Introduction
dontogenic infection is a poly-microbial infection [1]. Antibiotic prescription should be limited to acute abscess, presence of systemic signs and symptoms of periradicular infection, persistent exudate, symptomatic cases, and prevention of bacterial endocarditis [2]. However improper prescription of antibiotics can have side effects [3], such as development of antibiotic resistance [4]
Several strategies have been investigated for pain relief after root canal therapy such as narcotics, analgesics, intracanal and systemic corticosteroid, Non-Steroidal Anti-Inflammatory Drugs (NSAID) use, pulpotomy, partial pulpectomy and total pulpectomy. However, mild postoperative pain lasting for more than 72 hours is often managed by NSAIDs or acetaminophen [5, 6]. Corticosteroids are able to alleviate moderate to severe pain [7]. In light of these reports, this study aimed to assess prescription of antibiotics and corticosteroids after endodontic intervention by General Dentists (GDs) practicing in Qazvin, Iran. 
2. Materials and Methods
This descriptive, cross-sectional study was conducted on all GDs practicing in Qazvin City in 2016. The inclusion criteria were having a DDS degree and practicing in Qazvin. The exclusion criterion was unwillingness for participation in the study. The relevant data were collected using a researcher-designed two-part questionnaire. The first part asked for demographic data, including age, gender, graduation year, place of study, work experience, and sector of practice (private practice/ public service). 
The second part included questions regarding prescription of antibiotics and corticosteroids following endodontic procedures. This part of questionnaire included 16 questions. After designing the questionnaire, its validity was confirmed by the Shool  members of the Endodontic Department of Qazvin University of Medical Sciences, School of Dentistry. The Cronbach α and test-retest were calculated to be 0.8 and 0.76 for reliability. The authors distributed the questionnaires in person among the dentists. They were first informed about the purpose of study and ensured about the confidentiality of their information. 
After signing an informed consent form, the questionnaires were filled out by dentists anonymously. Phone number of one of the authors was written at the bottom of the questionnaire for contact. The next day, the questionnaires were collected by the authors and dentists were provided with correct answers. The answers were coded and data were analyzed using SPSS version 20 (SPSS Inc. IL, USA). The Mean±SD of variables were reported. The Chi-square test, ANOVA and Independent t-test were used to compare the collected data. The Pearson correlation coefficient was used to assess possible correlations. All tests were carried out at 95% confidence interval and P<0.05 was considered as statistical significance. 
3. Results 
Of 108 GDs, 77 contributed in this study. 26 (33.8%) were females and 51 (66.2%) were males. The majority of GDs (n=38, 49.4%) had been graduated from Tehran University of Medical Sciences. The Mean±SD age of GDs was 38.61±8.55 year. Their Mean±SD work experience was 10.96±7.67 year. The majority of GDs had private practice (n=26, 34%). Regarding the choice of antibiotic for endodontic infection in patients not allergic to penicillin, penicillin V (n=27, 35.1%) ranked first and amoxicillin (n=16, 20.8%) ranked second. Regarding the antibiotic of choice for endodontic infection in patients allergic to penicillin, clindamycin (correct answer), [8] ranked first (n=23, 29.9%) and second was metronidazole (n=16, 20.8%). 
Regarding the prescription of antibiotics for different conditions of pulp and periapical disease, the highest frequency of antibiotic prescription belonged to cellulitis (correct answer) (n=34, 44.2%), followed by pulp necrosis along with sensitivity to percussion test and preoperative pain and swelling before treatment plus cellulitis (n=9, 11.7%). Regarding the duration and dosage of antibiotics prescribed by dentists for non-allergic patients, 20.8% (n=16) of GDs prescribed 500 mg penicillin V four times a day (correct answer) [9], 15.6% prescribed penicillin V three times a day and 14.3% prescribed 500 mg amoxicillin four times a day. 
For allergic patients, 37.7% (n=29) prescribed 300 mg clindamycin four times a day (correct answer) [8], and 26% (n=20) prescribed 150 mg clindamycin four times a day. As regards persistent infection for more than 2-3 days after endodontic treatment, penicillin injection was prescribed by 24.7% (n=19) while metronidazole (correct answer) [10], was prescribed by 23.4% (n=18). Regarding life threatening infections, 44.2% (n=34) prescribed amoxicillin plus metronidazole and 16.9% (n=13) prescribed amoxicillin plus clavulanic acid (correct answer) [10]
According to Table 1, 28.6% and 13% of GDs knew the correct answer [1, 11]. Only one dentist selected both correct answers. Based on Table 2, the correct answer was acute heart failure, cardiac valve replacement, heart transplantation and recent joint replacement [12, 13]. None of GDs gave a complete correct response to this question. Table 3 revealed that only 6.5% chose the correct response, which was instrumentation beyond the apex, periodontal ligament injection and apical surgery [14]. In response to maxillary central incisor avulsion in a 7-year-old boy, 28.6% (n=22) of dentists prescribed penicillin V after replantation and splinting in the first session and 9.1% (n=7) prescribed doxycycline. 

Since both choices were correct [11], 37.7% gave a correct response. Regarding the route of administration of corticosteroids, 40.3% (n=31) chose extra-oral intramuscular injection; 13% (n=10) chose tablets and 9.1% (n=7) both. Regarding use of corticosteroids in conjunction with other drugs, 32.5% (n=25) reported using dexamethasone plus antibiotics and 22.1% (n=17) reported using dexamethasone plus NSAIDs. Table 4 shows that only 9.1% (n=7) gave a correct answer, since the correct answer was fungal infections and hypersensitivity to corticosteroids [6]
Regarding the need for administration of corticosteroids, 27.3% mentioned hypochlorite accident and 24.7% reported irreversible pulpitis with moderate to severe pain; 19.5% (n=15) reported pulp necrosis with periapical radiolucency and 50.7% (n=39) reported moderate to severe pain, necrosis and pulpitis. The common analgesics prescribed for severe pain following endodontic treatment were NSIADs, opioids and corticosteroids (correct answer) [7] by 48.1% (n=37), and NSAIDs, corticosteroids and opioids by 27.3%. Most dentists (n=50, 64.9%) stated that they would prescribe acetaminophen plus codeine for patients with gastrointestinal problems (correct response) [15]. The overall Mean±SD score of knowledge of dentists was 5.48±2.57 (range 0 to 11). Score 6 (n=12, 15.6%) had the highest frequency. 
Statistical analysis
The Pearson correlation coefficient showed a significant inverse correlation between knowledge score and age (P=0.04). The correlation of knowledge score and graduation year or work experience was not significant (P=0.887). The Independent t-test showed no significant association between knowledge score and gender (P=0.48). ANOVA found no significant association between knowledge score and the university attended (P=0.63) or working in private office or public service (P=0.25). 
4. Discussion
In this study, the list of antibiotics used in the questionnaire contained the most commonly prescribed antibiotics for oral infections [9]. The results showed that penicillin V was the first choice of most dentists and amoxicillin ranked the second (20.8%). In a study by Segura-Egea et al. amoxicillin was the antibiotic of choice. According to the guidelines, penicillin V is the antibiotic of choice for common anaerobic and facultative anaerobic pathogens [16]. Amoxicillin is a wide-spectrum antibiotic. Thus, its use in an individual with a normal immune system increases the risk of bacterial resistance [17, 18].
Regarding the route of administration and dosage of antibiotics, 20.8% reported prescribing 500 mg penicillin V four times a day; 79.4% of participants were not well aware of the correct dosage of chosen antibiotic. The first choices of antibiotic of dentists in our study in case of allergy to penicillin were clindamycin (29.9%) and metronidazole (20.8%), which was in agreement with the study by Martinez-Jimenez et al. who reported the first choice of antibiotic to be clindamycin (99%) [19]
In our study, 37.7% of GDs prescribed 300mg clindamycin four times a day and 26% prescribed 150 mg clindamycin four time a day. In our study, only 23.4% of dentists recommended metronidazole against obligate anaerobes and 24.7% prescribed penicillin injection for such patients. In life threatening conditions, simultaneous use of amoxicillin with clavulanic acid (co-amoxiclav) is required [20], which was reported by 16.9% of dentists in our study. Antibiotic prophylaxis is required in medically compromised patients with acute heart failure, valve replacement, heart transplantation and recent joint replacement [21]. None of the dentists gave a correct answer in this respect. Also, endodontic procedures requiring prophylaxis in patients include instrumentation beyond the apex and periodontal ligament injection; only 6.5% gave a correct answer in this regard [22]
All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa need antibiotic prophylaxis for patients at highest risk [22]. Inadequate knowledge in this respect calls for further continuing education courses and greater emphasis on this topic in dental curricula. Moreover, 44.2% of dentists reported antibiotic prescription for cellulitis; 55.8% prescribed antibiotics for irreversible pulpitis with severe pain, pulp necrosis with or without periapical lesion, and sensitivity to percussion. It seems that concerns of dentists regarding pain or flare-up are responsible for their wrong approach (antibiotic prescription). However, the correct treatment in such cases is root canal cleaning and administration of analgesics for acute apical periodontitis. There is no need for antibiotic prescription in such cases [23]. Therefore, further instructions on correct use of antibiotics in endodontics are imperative. 
Use of antibiotics in endodontics should be limited to the presence of fever, lymphadenopathy, malaise, or compromised cell immunity [24]. In our study, 28.6% of GDs prescribed antibiotics for fever and malaise, 13% for avulsion, and 10.4% for prevention of flare-up. Following avulsion and replantation and splinting of tooth in the first session, penicillin V or doxycycline is indicated [11]. About 28.6% and 9.1% of GDs prescribed penicillin V and doxycycline for such cases in our study, respectively; 22.1% prescribed no antibiotics. 
In case of avulsion, doxycycline is the antibiotic of choice and in case of risk of staining, penicillin V is the next best choice [11]. With regard to combined use of corticosteroids and other drugs, combination of dexamethasone and antibiotics, dexamethasone and NSAIDs and dexamethasone and antihistamine were reported by 32.5%, 22.1%, and 10.4% of GDs, respectively. According to a study by Stewart and Chilton [25], application of corticosteroids + antihistamine + antibiotics before or after conservative endodontic treatment is highly effective for decreasing acute symptoms postoperatively in case of severe infection, swelling or flare-up. However because corticosteroids have side effects, they are not routinely prescribed for systemic use for pain relief following root canal treatment. Several investigators have used them for pain management following root canal treatment [26].
In our study, only 9.1% of GDs gave a complete response to this question. Regarding the administration of corticosteroids, the only indication according to Bowden et al. is hypochlorite accident to resolve inflammation [27]. About 27.3% of GDs chose hypochlorite accident in our study. According to Torabinejad et al. corticosteroids decrease pain only in patients with moderate to severe pain [7]. In our study, 50.7% of GDs prescribed corticosteroids for moderate to severe pain. Systemic administration of steroids can significantly relieve moderate to severe pain in patients with pulp necrosis and periapical radiolucency [7]
In our study, 19.5% of GDs prescribed corticosteroids for pulp necrosis with periapical radiolucency. About 48.1% of GDs in our study reported prescribing NSAIDs, opioids and corticosteroids in case of severe post-endodontic pain. In patients with gastrointestinal problems, the analgesic choice of 64.9% of GDs in our study was acetaminophen plus codeine, which was a correct response [15]. The study reveals that participation of older dentists in education courses is significance. 
5. Conclusion
The majority of contributed dentists had inadequate knowledge about prescription of antibiotics and corticosteroids. Thus, continuing education courses seems imperative in this respect.
Ethical Considerations
Compliance with ethical guidelines

There was no ethical considerations to be considered in this research.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors contribution's
Statistic analysis: Fateme Sefidi; Design and data collection: Maryam Ghamari, Anita Ebrahimi Khaneghah; Writing and data collection: Sharareh Ghasemi.
Conflict of interest
The authors declared no conflict of interest.

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Type of Study: Original article | Subject: So on
Received: 2018/02/15 | Accepted: 2018/07/11 | Published: 2018/09/1

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